Last week, when New York legislators approved the New York SAFE Act on gun control, several people wrote in asking us to comment on mandatory reporting of dangerous persons to state authorities. Of course we couldn't keep quiet about such a topic, but interestingly, Clink and I had somewhat different interpretations and opinions about the legislation. We've both written articles over on Shrink Rap News on the Clinical Psychiatry Website and I'll invite you to surf over there to read:
The New York SAFE Act: New Duties for Psychiatrists (by ClinkShrink)
This has been very puzzling for me. The Immunity clause says that the decision to report or not report holds the professional harmless friom any legal action. So what burden does it exactly create? For instance, if a clinician does not create the impression in his notes that he is considering whether the patient is likely to harm others, who can know what has crossed his mind? If, on the other hand, he is in a clinic and has told others that he is considering whether the patient may be a danger, he then at least needs to explain his actions.
Tarasoff, in fact, only became an issue because the doctor went to the campus police with his fears, rather than to the police. It was incomplete, poorly thought out action that became the problem. If we have concluded that someone is a danger to himself or others we need to do something reasonable.
With Dinah, I am not sure why this law does not name all physicians, counselors, perhaps even all of us, rather than just mental health personnel. It sounds political rather than rational.
Personally, I don't see why anyone should have the "right" to own a weapon whose sole purpose is to quickly kill people, so I cannot become too upset over the effort to restrict that right. If guns were not owned by anyone with any mental health history at all it might prevent quite a number of suicides.
There have been a lot of letters in the media from people protesting that they do not want their "rights" infringed. Well, a short number of years ago people were upset that they were losing their "right" to own slaves or beat their wives and children.
As society advances we lose rights and we gain rights. Some rights need to be lost.
From Clink: "[SAFE] now requires protective order respondents to surrender their weapons and the judge granting the order to revoke the firearm license of the respondent"
Probably will not pass constitutional muster. Confiscation of lawfully owned property from citizens innocent of crimes? I don't think so!
From Dinah: "Interestingly, in New York, you can still tell your internist or dermatologist that you’re feeling suicidal, and that doesn’t need to be reported to the state"
Dinah, tangentially, touches upon what is the essential enormity of SAFE, that is, a therapist is compelled (without threat of sanction, I'll grant) to act based on his or her subjective state. For example, if it enters my mind that person X might kill somebody, I am required to report this to the state.
Doesn't anybody get it? The State is requiring you to act based on your THOUGHTS!!!
This is not the first such example as thought-related legislation. Section 51A of the Massachusetts criminal code requires mandated reporters (I am one, BTW) to file reports based on SUSPICION of abuse or neglect.
Suspicion of neglect.
You wanna go on living in that world, enjoy! Me? I'm writing my congressman (as if he'll listen: this is Massachusetts)
can't read those without becoming a registered member of the site. can you summarize?
also, malpractice insurance (psychiatry) in NY currently advising a wait and see attitude.
I posted mine on Psychology Today, no password. Or be me, user dinahmiller,
I find the New York law to be very scary, and the executive orders aren't much better.
I wonder how many people in NY will end up failing routine background checks for employment, all because they confided in their therapist or psychiatrist that they had suicidal thoughts and were subsequently reported. Sad that New York believes it's a good idea to punish people for seeking help. With a plan like this, not sure why anyone would go back. I would not.
I am watching my state closely to see what they do with this, and if it looks anything like what NY has done, then I will not continue seeing my psychiatrist. I saw a psychiatrist to help make my life better, not make things worse. I am no danger to anyone, and I don't want to have to worry about every word that comes out of my mouth and chance that it might ever be misinterpreted or that my psychiatrist might overreact.
Jesse, would you be ok with it if we targeted men and put them in a database or is it just people with mental illness that are fair game? Would it be fair to limit your rights but not mine, simply because you are male and males are statistically more likely to commit violent crimes? Targeting people with a diagnosis is doing the same thing, it is holding me accountable for the actions of others. I don't hurt animals, and I don't hurt people. I'm not interested in being penalized because of the actions of people who do. It has nothing to do with owning a gun, it has everything to do with expecting to have the same rights and freedom as any other person who has not committed violent crimes.
It's ludicrous that the people who will end up in this database are largely the people seeking help. I guess the sociopaths will not be in that database unless they get arrested. Yes, by all means lets fill a database full of people who will never shoot up a school, while failing to capture those who would. Sounds like a plan guaranteed for success!
Even I (the extremist of our Shrink Rap team) don't believe it will come to this. Therapists don't want to report their patients, and no one is suggesting that people be reported to the state for suicidal thoughts or ideas, or that the information be used for jobs...gun ownership/ maybe health insurers would find a way to get it...but not jobs. The law requires reporting people you believe are LIKELY to be violent (something shrink don't predict terribly well over time). As it stands now, if you tell a therapist that you are planning to kill yourself (not thinking, not toying with the idea, but going to do it imminently --not in 3 years), you're likely to end up in a hospital and if you don't go voluntarily, that information may well be in a databank that prevents you from buying a gun. From the 'thought police' issue, it's not the patient's whose thoughts are being policed so much as it is the shrinks: Do I think someone is likely to commit a dangerous act? I don't believe private practitioners will report patients unless they really believe someone is dangerous and the therapist is losing sleep worrying about the patient.
I don't believe that the 2nd amendment gives everyone the right to own a gun, and I'm wondering why you don't need to renew your gun license every few years the way you have to renew your driver's license and prove you can still see well enough to drive safely.
I don't like guns because they are very lethal and allow for a degree of impulsivity, whether it's suicide, or losing your cool and shooting someone you're arguing with.
@anon, I agree with Dinah above. The requirement is to report to this database people who the mental health professional thinks likely to commit a violent act. At the present one can have a patient held for observation for three days if two doctors (Maryland, I don't know New York) have found him to be a danger to himself or others. So, would any professional report a patient that he is not already having hospitalized? If he does one he needs to do the other. As Dinah said, psychiatrists are very reticent to put labels on anyone.
What I meant was that I don't think anyone who has been depressed, suicidal, or has suicidal/impulsive/substance abusing (this is a short list) people in their home is wise to have a gun. I know people whose family members killed themselves with guns that the parents were keeping for protection.
So the idea that we need to hold on to our "right" to keep a totally lethal, easily misused weapon in our homes strikes me as strange. We want to protect our "rights" despite how much harm comes from them.
I say we ban structures higher than six feet high. Any higher than constitutes a lethal height, off of which an impulsive person, mentally ill or otherwise, may hurl himself.
Perhaps we should lobby the Maryland State Legislature to require therapists to report "dangerous" people who live in tall buildings?
I am a psychiatrist in New York and am reading this blog with interest, while the issue is flooding me with anxiety. There is nowhere else on the internet that I can find a conversation in which psychiatrists and others are grappling with this issue in a serious way, in particular, by trying to understand the large social and political implications rather than imagining only one's own professional self-interest (will "we be" held liable, will there be sanctions, will we lose patients.,? etc). Does anyone know of any other sites where people are taking this pending legislation seriously--I would appreciate some references.
I will say that, for my part, this is a very precarious moment for our profession, and there have been many others in which we have not acted when we should have. I believe that we need to do what Nancy Reagan suggested in a very different context many years ago--just say no. We will not do this. As a group we need to take a political stance that we will not and cannot allow ourselves be turned into the thought police regardless of how "tame" or "toothless" present legislation may seem.
If we do not believe that we are capable of predicting violence, we need to say so and refuse to be asked to do so. If we have skills in fact that can be used to decrease the violence in society, we should be making suggestions about how we can, as professionals, best implement them--not be told by the government that our new and additional job will be to work for the government as spies.
One would have to have a lot of regard and trust in government to do so. Is that our professional position? We are trusting New York State, et al and our great legislative body there to figure out how to use us best to stop violence.
Anyone who has not yet seen the movie "The Lives of Others" should watch it.
If this legislation comes to pass, in whatever form, I also suggest that we flood the "mental health offices" with our genuine concerns about the dangerousness of our politicians and members of the social elite who are destroying our planet. If psychiatrists are to be taken as seriously as this legislation would suggest, let's go for the big guys who are building bombs and drones, the sociopaths in big industry and who are fracking under farm lands. Are they homocidal? Sociopathic? Dangerous? Violent" Certainly they are, and if we are to report our "patients", we should be letting the government know that we intend to be reporting them.
The problem with this law is that it asks Psychiatrists to do something we can't - it asks us to predict violence.
We're terrible at predicting which patients will be violent in the future.
We already have Tarasoff and 72 hour legal holds. This law doesn't improve safety, it increases the stigma against mental health while also increasing the liability for psychiatrists.
I wrote about this more in depth last week:
P.S. ShrinkRapers - thanks for adding me to the Blog Roll. I was rather surprised since my blog isn't strictly about mental health, but about all random topics and books I read.
Dinah & Jesse,
Thanks for your response to my comment. The problem is your interpretation of "likely to be violent" might look very different from my psychiatrist's or a another therapist's interpretation. I don't know what's in my psychiatrist's head, and I don't know if he sees things the same way you do. The problem with it being left up to interpretation is that interpretations are going to vary. I don't want to have to worry about everything I say and how it could be interpreted. So, I will probably opt out if that law is passed in my state. It would be too anxiety provoking to constantly be on guard that something I said or didn't say concerned him enough to report me.
I think a therapist or psychiatrist's reporting of a patient as "likely to be violent" very well could have an impact on that patient's ability to obtain future employment. What's going to keep that data out of a FBI background check?
I would love to hear what NY psychiatrists are saying about this law. We wrote our opinions on Clinical Psychiatry News, and I put my article (the same one) up on Psychology Today as well, but I have not heard any one say much. Can you ask your NY colleagues their opinions and send them to us? I'd use them for a post. I forwarded your comment to an APA assembly member. I've let people on our Maryland listserv know that I think APA should be opposing this.
Anon, might you share your concerns with your shrink?
This is so weird. I've tried commenting on this post twice now and Blogger has eaten my comments. It's not in the spam filter and not in the moderation cue. At least our readers know now that it's not just happening to them.
For the third time:
Psychiatrists can't be selective about their use of risk predictions. They use risk prediction all the time when they decide to discharge someone from an inpatient unit, or when they decide not to admit someone from the ER, or when they seek involuntary medication for a patient. You really can't hide behind a "prediction incompetence" defense when it comes to gun reporting laws when you do it routinely for involuntary treatment.
Even people with no clinical training have a duty to make risk predictions. Court commissioners predict risk when they grant bail to defendants. Parole hearing officers predict risk when they let offenders out of prison. Judges predict risk when they give someone probation instead of incarceration.
No one expects a risk assessment to be 100% accurate. It only has to be done carefully, using acceptable professional judgment and good faith. We're actually not that bad at it, and we're quite good at predicting safety (which we do much more frequently than predicting dangerousness).
The SAFE act takes this into account by requiring, as a first step, that the risk assessment and clinical scenario be reviewed by another mental health professional. If and only if the second professional agrees does the report go to the "do not buy guns" list. No clinical information is reported, just basic identifying data. And they are required to destroy the information after five years. It can be destroyed sooner if the patient petitions to have it removed.
Bottom line: as far as gun legislation and our patients go, the SAFE act could have been a lot worse. I'm sure we will see worse laws proposed.
The only alternative to this risk prediction model of gun control would be to have one that is based solely on a judicial determination of dangerousness separate from clinical prediction. For example, by having anyone who has been civilly committed or found insane placed on the 'do not buy a gun' list. Apparently this is the Federal law which most states have been unable to comply with because background checks don't have commitment information.
But these are the two models I think we'll be dealing with in regard to psychiatric patients and guns: either psychiatrists predict risk or there will be a judicial determination.
I can tell you that in my rural area, a LOT of patients are going to start lying to their psychiatrists and therapists if a law like this one passes in our state, or other types of restrictions. I know a lot of people won't go into treatment any more, and those who are in treatment will drop out. I will certainly drop out of treatment over this issue. I don't want to be put into a database as if I am a criminal!
Virtually every man in my area hunts deer and ducks, and a very large number of women, too. It is MAJOR part of a rural lifestyle. Two men I hunt with have also seen psychiatrists before.
In addition, the sheriff is more than a half hour away for most of us in this county, and potentially much further away in counties north of me. There are two sheriffs on patrol in a county about 30 miles by 60 miles. I don't keep a gun for home defense, but I certainly don't begrudge someone the right to do so if they want, given how long it takes the sheriff to arrive.
Can't understand how hunting is part of the lifestyle? Maybe you come from a family of musicians, instead of hunters, and music has always been part of your life. Instead of the quiet woods on a snappy winter morning, with the lake singing as it puts on ice, for you it is the music your family plays that swells your heart with joy. Now, someone passes a law that you aren't allowed to own a musical instrument, or be around someone who is using a musical instrument. Talk about sucking the joy out of someone's life! Hunting is the same thing!
People who live in nice neighborhoods in the city or suburbs should not decide what is right for people in bad neighborhoods or in the country. Guns are NOT only for killing people. That is your city views coming out, lawmakers being just more city people legislating for people in the country and it doesn't work.
"Guns are NOT only for killing people..."
Jesse, please read this carefully. It's true that those of us who have lived our entire lives in cities (and I am one) tend to see the world through the prism of a city-dweller!
Dinah is the only respondent who has been honest about this: substantial numbers of Americans dont like guns.
Let us please dispense with this talk about dangerousness and impulsivity when it comes to guns and mental illness. At its source, this issue is about dislike of guns.
Cat Lover, my sentiments exactly.
A lot of this is coming from people who have absolutely no idea or understanding of what it's like to live in a rural area where it's more common than not to have guns in the house. My dad and brother spent a lot of time hunting and fishing. I wasn't much interested in it, because I had other interests. Low violent crime rate in the area I grew up in, and I never knew of anyone who got shot. People who have grown up in another culture don't get it.
It's not just Cat Lover and myself who are re-thinking continuing with treatment, I know of others as well. If something like this passes in my state, you can count on many therapists and psychiatrists losing patients. They need to think about that.
Cat-lover, Anon, and others,
There is, in fact, another imperative at play here, and it has to do directly with the second amendment.
The constitution granted citizens the right to bear arms precisely because otherwise the State would have sole and unchallenged access to them. The second amendment, seen this way, is not so much about allowing citizens to hunt (and to defend their homes, but I digress), but to protect themselves from a rapacious strong central government
Then, let it be the judicial system that deals with this, not us.
What you are describing is exactly where totalitarianism comes from; professionals begin to find their strength and identity as being agents of the state.
Even if we do have "powers of prediction [of violence in this case]", how does this translate that these "powers" belong to the State. And, by the way, as a practicing psychiatrist I completely disagree with you that we "use our powers of prediction all of the time." I cannot use my powers of prediction to get patients longer stays in hospitals--that is the decision of insurance companies. I cannot use my "powers of prediction" to get my patients the level of psychiatric treatment that they need--that is also the decision of insurance companies (which have decided not to provide it).
As I see this, as psychiatrists have lost real "power",-- and by this I also mean intellectual and analytical "power", the power of being a coherent and live profession;, the power to choose the nature of the treatments we use and to define the nature of our work and workplace--the more we have been willing to be drawn into unholy alliances with government and industry that are far afield from our real purpose, and fundamentally undermining of it.
I believe that the work that we do, at its best, is fundamentally about helping people learn to negotiate cooperative models of relationship and intimacy. There are fundamentally two models of social interaction: coercion or cooperation. I believe that psychiatrists need to be on one side or another of these two models, and I hope they will choose to be on the latter. We cannot agree to a model of coercion on the one hand and continue to preach/teach models of trust, empathy and intimacy on the other.
I will also say that I increasingly have come to think that "reporting' on our patients' "potential for violence", etc., violates our professional commitment to "do no harm", our most fundamental as physicians. We do not, indeed, know what will be done with "information" that we are being told to provide, now or in the future. How can we therefore protect our patients from harm unless we believe, with profound naiveté, that the state will/can do no harm to them, now or in the future with such information.
Psychiatrists do have one extraordinary power that remains uniquely ours: the power to decide what mental illness "is," and what it is not. At this moment, in my judgment we are about to be coerced into turning over this extraordinarily complex set of observations and judgments against our own personal, professional and ethical interests and against our better judgment to the state/State to use as it pleases.
This is not in anyone's interest: on the contrary, if we in any way respect what we do and the complexity of the decisions that we make, we need absolutely to resist being turned into a tool of the American judiciary.A simple look at our system of "justice", let alone the erosion of civil liberties and privacy in our country, should be enough to convince us to absolutely refuse to go along with legislation that makes us passive accomplices to these failing systems of abusive, excessive state power.
HarrietMD is my new favorite psychiatrist
In response to the comment you addressed to me yesterday, THANK YOU for sending my comments on to the APA. I do not belong, as you can well imagine but boy do I want them to know what I think.
I am, obviously, apoplectic at the moment, but today tried to state more clearly, and as less of a rant, what I think about the SAFE act and the issues it raises for psychiatry.
I do not know particularly what my colleagues are thinking about the law; I too wish I did. I am in private practice and though I do have colleagues as a child and adolescent psychiatrist I am even more out of the mainstream. Most of my friends are social workers and psychologists, and they don't appear to understand what is happening here. My impression is that people are ducking, as usual; they hope that whatever is happening will not ruin their business or their lives. People feel entirely disempowered.
So, little is being said but I would be happy to try to reach out to some quarters and let you know what I find.
Thanks for the blog! I discovered it after doing a search about the new cpt codes under a heading like "resistance to new cpt coding rules", and ShrinkRap popped up. A topic for another day but not altogether different issues to my mind...
I'm sure that you do periodic assessments of suicide and violence risk as part of your routine clinical practice. You may not do this on a rotely conscious level at every appointment, but awareness of risk and an assessment of it is part of general psychiatric training and regular practice. When you express frustration (which I would share in your situation) that you can't get the level of care or length of stay you think the patient needs, you base that on an assessment. Whether or not that assessment gets respected or ignored from an insurance company is a separate issue.
Certainly psychiatrists can call on legislatures, through a professional organization or as individuals, to shape gun laws around a judicial determination rather than a clinical recommendation. The purpose of my comment was to outline the potential models or options.
I think the one option that isn't available to us is the decision to throw up our hands in protest and refuse to participate. That quest was lost 20 years ago when the Tarasoff duty to third parties was imposed upon us. If you take the stance that psychiatrists just simply shouldn't be involved in the gun regulation question you run the risk of a similarly imposed obligation.
This is a far cry from turning our profession into an arm of the police. Certainly there are situations in which it would be potentially helpful--maybe even lifesaving--to know for sure if a gun were still in the home or had been removed, or if a high risk patient had attempted to purchase a weapon. This information could be a crucial determining factor in a treatment plan or a discharge decision.
I share your concern about patient registries and databases. (In fact, when our state launched a healthcare information network I opted out immediately.) This is why I tend to favor a clinically determined discretionary model rather than a judicial model. At least then we'd have some control over who wouldn't go into it. The clinically stable, formerly depressed patient in remission who needs a rifle to shoot groundhogs (regardless of my feelings about groundhogs) wouldn't need to worry about her doctor when they've already discussed the gun issue and have a plan for managing it in case of relapse.
I disagree with Jesse who said:
"Personally, I don't see why anyone should have the "right" to own a weapon whose sole purpose is to quickly kill people".
Many guns such as Thompson Center Contender with .22LR barrel, are single shot, with small caliber, made for target shooting.
Should someone with mental health issues never be able to target shoot again? I think they ought to be able to target shoot again.
Right now the mentally ill are being used as a scapegoat. Even the conservative right who believe in 2nd amendment right to bear arms is blaming "crazy people" as the culprit of all gun deaths. Why? Because that takes the heat off of all felons, thieves, gang members, wife beaters, and lays it all at the feet of people who have been depressed. People who seek mental health help are the sacrificial lamb, so everybody else can go on with gun ownership.
Why is it that mental health professionals such as yourselves think that once a person has a single episode of mental health issues that they will never be well? Why is it that one incident of seeking help for mental health problems should mean a lifetime ban, but felons can go back to owning guns?
Look in Wikipedia's article about Canadian gun laws. They put in strong bans on guns, and the suicide rate stayed the same. The same. How could that be? Well, there are other ways to kill yourself than by gun. You and the legislatures ought to know that.
Wait, I'm supposed to be sympathetic to shooting Bambi and little woodchucks (as in "how much wood would a woodchuck chuck if a wood chuck could chuck wood?") as an inalienable right? We hold these truths to be self -evident...wait, I have to run, my cat quiche is burning.
Damn blogger I am not a robot.
Posting for Jesse:
@Sunny, CatLover, et al, I am not at all against people owning guns for hunting or target shooting. I specifically referred to weapons whose sole purpose is killing people. Assault rifles, for instance. If all the handguns would disappear, I would be for that, too, as many tragedies occur through them and little good (I recognize that criminals are not giving up their handguns, so what I am talking about is a wish). I do believe that we hear too much about "rights" and too little about responsibilities to others. One needs to balance the other.
Clink referred to the duty that Tarasoff conferred on mental health professionals, and of course she is right, but here is another way to look at it: Tarasoff freed us to be able to do the reasonable and right thing without the fear of retribution, lawsuit, or other penalty. The doctor in Tarasoff had concluded his patient was likely to kill her. He then told the campus police. This was woefully inadequate action; she was killed by him as the doctor feared would occur. He could have warned her, hospitalized him, or alerted the police. His duty was not to his patient alone, and even if it were he did not act to protect the patient.
So this is not at all the police state stopping us psychiatrists from treated our patients, but recognizing that in certain circumstances there are duties to society that override those to the individual.
Remember Mike McQueary who actually saw Sandusky in the shower with a boy, committing a sexual act? He told his superiors not the police, and other children subsequently were abused. If he had been freed from the threat of losing his job perhaps he would have told the police, as most people recognize he should have done.
I agree with SunnyCA. Those of us who have diagnosed mental illnesses now or in the past are scapegoats. It will probably all shake out in the long run, but I have no intention of getting swept up in whatever mental patient sweeps appear in my state in the meantime.
I am not sure what Dinah meant. I like woodchucks, but they are voracious, wasteful foragers, and go down a row and literally eat the centers out of 12 big cabbages a day. Even an electric fence won't work. They find a way. Yeah, Peter Rabbit was nothing.
I have not tried kitty quiche or burgers yet.
Governments historically do not show sincere interest or concern for the mentally ill population. Um, are some forgetting the stat that about $9 billion was slashed from state budgets in the past 3 + years? And now they are claiming an interest to improve services, only after 20 children and 6 adults were brutally slain by someone with ALLEGED mental health issues?
WHEN the first psychiatrist or therapist fails to identify the NEXT shooter, whether or not there is a valid Axis 1 diagnosis to the situation, what will be gained? Just another scapegoat for politicians to deflect the real blame.
We live in a gray world, foolishly bounded by black and white interpretations too many times. But, we get the electorate we deserve.
The problem is that what you determine is "reasonable" has everything to do with your personal political beliefs. We clearly grew up in very different cultures. My parents are gun owners and very responsible people. When we were children, they did not leave guns lying around, they put up toxic cleaners and medications, they put the little plastic covers over the outlets. Low crime rate in the area I grew up in, and everyone I knew had guns in their houses. No one got shot. Maybe it had something to do with the gun owners being responsible people. Don't hold other gun owners accountable for the irresponsibility of others. That's not a fair thing to do.
As a psychiatrist who has worked in New york for over 40 years this law is terrifying. Patients will quickly learn the lasting consequences of "going for help" and those who are at high risk will avoid "help"like the plague.I suspect suicide rates will climb fairly quickly.The law ,in effect, criminalizes depressed human beings and places unfortunate souls on some government data base with what ultimate consequence(s)? How can you ever hope to help any patient when we become agents of the state and possess these powers (potentially ) over our patients ? My personal and professional ethical beliefs will force me to stop practicing in NY. I love my work and had hoped to work as long as my health allowed me to. Thanks to the " State " this hope has been dashed.
I am glad for psychiatrists like HarrietMD and the last anonymous.
Catlover, Brere Rabbit liked to be thrown in the briar patch. He would say "don't throw me into that briar patch" to get Brere Fox to do it. Who is Brere Rabbit in this current situation? (The briar patch is the firearm reporting requirements.)
(I know you said Peter Rabbit, but he's lame, losing his mittens and all that. I do believe Farmer MacGregor used a rifle. Nowadays, PETA would get him committed to take his weapons.)
On January 26 I posted a comment as Anonymous. To distinguish me from others who post as Anonymous I shall henceforth post as "Geezer MD"
On January 26 I posted a comment as Anonymous. To distinguish me from others who post as Anonymous I shall henceforth post as "Geezer MD" (oops I' m the 2nd Anonymous for January 26)
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